Alexis Totaro, MSN, on distinguishing postpartum sleep disruption from psychosis

Distinguishing normal postpartum sleep deprivation from an emerging psychiatric concern — and screening directly for postpartum psychosis — requires clinicians to look beyond exhaustion to how patients sleep, think, and perceive reality, according to Alexis Totaro, MSN, RN, WHNP-c, CARN-AP, Vice President, Mental Health Operations, and Chief Nurse Executive, Christian Health.

Totaro said normal sleep disruption and impending depression or anxiety can be difficult to tell apart, with sleep behavior serving as a key differentiator.

“When you're looking at a normal adaptation to having a new infant or another infant in the house, or sleep deprivation from an infant, patients are exhausted, and so when given the opportunity to sleep, if it's just sleep disruption from having a new baby, they will usually readily fall asleep,” she said, noting that these patients welcome the chance to rest and feel refreshed and happy afterward.

An emerging psychiatric concern could present differently, she said.

“When we're looking at an impending postpartum depression or anxiety that's keeping someone awake, that's a whole different ball game. That usually involves unwanted and intrusive thoughts. They're constantly worried about the baby, and so sleep does not come readily to them at all. There is not a feeling of feeling refreshed once they have slept, and it's ongoing, unwanted, intrusive thoughts,” Totaro said.

She emphasized that postpartum psychosis is distinct from depression and requires assessing whether a patient is grounded in reality.

“You do want to make sure that someone is based in reality... but are they tilting their head and appearing as if they're hearing voices that no one else is hearing? Are they seeing things that other people are not seeing? Are they looking suspicious or paranoid?” she said, noting these signs can also be subtle.

Because patients may conceal what they are experiencing, Totaro said clinicians should ask directly.

“A clinician should be asking outright in the postpartum visits, or if there's a visit because family is worried and they've brought their loved one to a clinician. We have to be comfortable saying: ‘Are you hearing things that other people may not be hearing? Are you seeing things that other people may not be seeing? Do you have thoughts of hurting yourself, or your infant, or anybody else in the household?’” she said, describing those questions as essential to determining whether a patient is based in reality.